Physical Examination of the Cardiovascular System

Introduction

• Heart location: Under rib cage, between lungs.
• Heart size: Varies with age, size, and condition; roughly the size of a clenched fist.
• Four chambers: Right atrium, right ventricle, left atrium, left ventricle.

Heart Anatomy

• Atria: Upper chambers that receive and collect blood.
• Ventricles: Lower chambers that pump blood out.
• Septum: Muscle dividing the heart into right and left halves.

Heart Valves

• Four valves: Tricuspid, Pulmonary Semilunar, Mitral (Bicuspid), Aortic (Semilunar).
• Function: Prevent backflow, ensure unidirectional blood flow.

General Inspection

• Pallor: Best seen in mucous membranes; indicates anemia, possibly with sinus tachycardia or heart failure.
• Cyanosis: Blue discoloration from increased reduced hemoglobin (5g/dl).
  • Central: Reduced arterial oxygen saturation due to cardiac or pulmonary issues.
  • Peripheral: Cutaneous vasoconstriction, reduced cardiac output.
• Finger Clubbing: Soft-tissue swelling of terminal phalanges; associated with congenital cyanotic heart disease or infective endocarditis.
• Inspect Anterior Chest: Scars, deformities (pectus excavatum/carinatum), visible pulsations (ventricular hypertrophy).
• Edema: Tissue swelling from increased interstitial fluid, CHF cardinal feature, prominent in ankles (ambulatory) or sacrum (bedridden).
  • Advanced CHF: Edema in legs, genitalia, trunk; ascites, pleural/pericardial effusion.

Palpation

• Temperature: Assess with dorsal hand aspect; cool hands indicate poor perfusion.
  • Cool, clammy hands: Acute coronary syndrome.
• Capillary Refill Time (CRT): Assess peripheral perfusion; normal is less than 2 seconds.
  • Prolonged CRT: Poor perfusion (hypovolemia, CHF).
• Palpate:
  • Heave: Left sternal angle
  • Thrill: Palpable murmur
  • Apex beat: 5th intercostal space mid-clavicular line; lateral displacement indicates ventricular hypertrophy
• Parasternal heave: Right ventricular hypertrophy.
• Thrills: Palpable murmurs over heart valves.

Auscultation

• Pattern: Quiet room, patient at 30° elevation, diaphragm then bell.
• Heart Sounds:
  • S1: Mitral and tricuspid valve closure, systole onset, best at apex.
  • S2: Aortic and pulmonary valve closure, end of ventricular ejection, best at base.
• Timing: Palpate the carotid pulse.
  • S1 precedes carotid upstroke, S2 is out of phase.

Abnormal Heart Sounds

• S1 Intensity:
  • Quiet: Low cardiac output, poor left ventricular function.
  • Loud: Increased cardiac output, mitral stenosis.
  • Variable: Atrial fibrillation, extrasystoles.
• S2 Intensity:
  • Quiet: Low cardiac output, calcific aortic stenosis.
  • Loud: Systemic or pulmonary hypertension.
• S2 Splitting:
  • Widened: Right bundle branch block, pulmonary stenosis.
  • Fixed: Atrial septal defect.
  • Reversed: Aortic stenosis, hypertrophic cardiomyopathy.

Third and Fourth Sounds

• S3: Rapid filling in early diastole after AV valve opening.
• S4: Late diastole due to atrial contraction.

Heart Murmurs

• Systolic: Between S1 and S2.
• Diastolic: After S2 and before S1.
• Pulse trick

Identifying Murmurs

• Timing: Systole/diastole, duration.
• Location: Precordium location, radiation.
• Maneuvers: Patient position.
• Shape: Crescendo, decrescendo, holosystolic.
• Intensity: Grade 1-6, pitch, quality.
• Associated Features: S1/S2 quality, extra sounds.

Heart Murmur Locations

• Aortic Area:
  • Systolic: Aortic stenosis, flow murmur, aortic valve sclerosis.
  • Diastolic: Aortic regurgitation.
• Pulmonic Area:
  • Systolic: Pulmonic stenosis, atrial septal defect, flow murmur.
• Tricuspid Area:
  • Holosystolic: Tricuspid regurgitation, ventricular septal defect.
  • Diastolic: Tricuspid stenosis.
• Mitral Area:
  • Holosystolic: Mitral regurgitation.
  • Systolic: Mitral valve prolapse.
  • Diastolic: Mitral stenosis.
• Erb's Point: Diastolic murmur (Aortic or pulmonic regurgitation), systolic murmur (hypertrophic cardiomyopathy).

Systolic Murmur Types

• Midsystolic: Starts after S1, stops before S2.
• Pansystolic (Holosystolic): Starts with S1, stops at S2.
• Late Systolic: Starts mid- or late systole, persists to S2.

Diastolic Murmur Types

• Early Diastolic: Starts immediately after S2, fades before next S1.
• Middiastolic: Starts shortly after S2, may fade or merge into late diastolic.
• Late Diastolic (Presystolic): Starts late in diastole, continues to S1.

Continuous Murmurs

• Starts in systole, extends into diastole.

Murmur Shapes

• Crescendo: Louder.
• Decrescendo: Softer.
• Crescendo-Decrescendo: Louder then softer.
• Plateau: Constant intensity.

Murmur Grading (Levine Scale)

• Grade 1: Very faint.
• Grade 2: Quiet, heard immediately.
• Grade 3: Moderately loud.
• Grade 4: Loud, with palpable thrill.
• Grade 5: Very loud, with thrill, heard partly off chest.
• Grade 6: Very loud, with thrill, heard entirely off chest.